Question

Myocardial Infarction

Patient Profile

F.M. is a 68-year-old white man who comes to the emergency department (ED) in the early afternoon with a 2-day history of severe chest pain. The pain started on wakening the previous day. The pain increased during the night, but his wife could not convince him to go to the hospital. He comes to the ED today because the pain is severe and no longer relieved by rest.

Subjective Data

• Describes recurring chest pain for the past 6 months that was relieved by rest; the pain is a feeling of heaviness in chest with no radiating pain to arm or jaw or accompanying complaints of nausea or dizziness
• Recently the chest pain has become severe and is no longer relieved by rest; is now complaining of being slightly nauseated

• His father died of a heart attack at age 62
• Denies alcohol or drug use
• Smokes one pack of cigarettes per day
• Describes his lifestyle as sedentary

Objective Data

Physical Examination

• Blood pressure 180/96, pulse 98, temperature 99.8° F, respirations 20
• Height 5’11”,weight 210 lbs, BMI 29.3 kg/m²
• Alert and oriented to person, place, and time
• Skin diaphoretic and clammy
• Heart rhythm regular, no murmurs or extra heart sounds
• Lungs are clear to auscultation

Diagnostic Studies

• Hemoglobin 14 g/dL
• Chemistry panel is normal
• Cardiac markers – pending
• Electrocardiogram showing changes that correlate with non–ST-segment–elevation myocardial infarction (NSTEMI)

Interprofessional Care

• 0.9% NaCl infusing into IV catheter at 75 ml/hr
• Nitroglycerin and morphine given with relief of pain

Discussion Questions

1. What are F.M.’s modifiable risk factors for coronary artery disease (CAD)? What are his nonmodifiable risk factors?
2. What is the difference between chronic stable angina pain and pain associated with myocardial infarction?
3. What diagnostic studies are indicated for F.M.?

Case Study Progression

F.M. is diagnosed as having a myocardial infarction (MI).

1. What is the priority nursing care for F.M.?
2. What other interventions do you anticipate for F.M. at this time?
3. What are common complications after an MI?

Case Study Progression

After an uneventful hospital stay, F.M. is preparing for discharge.

7. Prior to F.M.’s discharge from the hospital after having an MI, what patient teaching should he receive?

Answer 1

ANSWERS FOR DISCUSSION QUESTIONS:

• F.M'S modifiable risk factors for CAD are
• control of high blood pressure
• cessation of smoking
• Weight reduction.
• F.M'S non modifiable risk factors for CAD are
• Age
• Family history
• Gender.

• Pain in chronic stable angina occurs with exertion,increased emotional stress, it usually lasts not more than five minutes and is relieved by rest whereas pain associated with myocardial infarction(MI) occurs abruptly and does not relieve by rest.
• Pain in chronic stable angina occurs when there is a narrowing of the coronary artery which leads to decrease in blood flow to heart whereas pain associated with myocardial infarction(MI) occurs when there is a blockade in coronary artery usually due to plaque or clots.

Diagnostic studies indicated for F.M are:

• Cardiac enzymes test - CK MB, Trop T and Tro I.
• 2D Echo
• Coronary angiogram(CAG)
• Serum electrolytes.

CASE STUDY PROGRESSION:

• The priority nursing care for F.M is to relieve his pain with relevant medications(usually morphine given as iv boluses) and to reduce his anxiety.

• The following are the interventions for F.M:
• Administer oxygen along with pain medications to ease the pain and also to prevent hypoxia.
• Elevate the backrest of the bed to ease the pain.
• Monitor the vitals and heart rhytm and inform the concerned physician to prevent complications.
• Monitor urine output.

Common complications following a myocardial infarction are conduction abnormalities such as arrythmias, myocardial rupture, aneursyms etc.

CASE STUDY PROGRESSION:

• The teaching points to F.M should include that he should immediately report if chest pain occurs, advise him to stop smoking and to reduce weight by making dietary changes.
• Instruct the patient to reduce stress, anxiety by practising relaxation techniques.
• Instruct the patient regarding adherence to treatment and follow up.

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